Foot and Ankle
The Cumulative Effect of Activity
Many people are put off from starting an exercise routine because they are overwhelmed by the time commitment they feel is necessary. Fitness magazines, exercise experts, and everything on youtube preaches–
–30 minutes of cardio three times a week
–45 minutes of strength training twice a week
–150 minutes of exercise per week
Most of this well-intentioned advice is wrong. Nearly everyone can derive significant benefit from short bouts of fitness activity that are performed on a consistent basis. Walk for five minutes twice a day. A simple routine of two strengthening exercises will take no more than five minutes. Climb the stairs in your home three times once a day. Practice getting up and down of the floor. Stay consistent with a routine of short exercise bouts and you will be healthier and stay independent for a lifetime.
More research has demonstrated the beneficial effect of short exercise sessions interspersed throughout the day. Read the March 28, 2018, New York Times article by Gretchen Reynolds, Those 2-Minute Walk Breaks? They Add Up. View the article: https://www.nytimes.com/2018/03/28/well/move/walking-exercise-minutes-death-longevity.html
Mike O’Hara, PT, OCS, CSCS
Triathlon Success: Hamstring And Glute Togetherness
To keep a triathlete healthy and resilient, the hamstrings and gluteal muscles must work together as a team. The athlete fires the gluteals and hamstrings simultaneously to stabilize the pelvis and produce force through the lower leg. When you run, bicycle, or swim, these muscles work at a team to produce efficient propulsion and reduce stress on the lumbar spine and knee. A triathalon is the ultimate long duration physical endeavor. Triathletes need hamstrings and gluteal muscles that can stay on and strong for a long time.
Most fitness programs do not properly train the muscle of the posterior chain. Fitness center exercise generally involves training the hamstrings as knee flexors on some type of “leg curl” machine. Gluteal training rarely occurs past neutral hip extension, with little effort on improving overall hip range of motion. Any type of seated gluteal training is inappropriate for an athlete.
The term physical therapists and strength coaches use for butt muscles that are non- responsive is “gluteal amnesia”. Our sedentary lifestyle involves very little of the glute recruiting sprinting, deep squatting, and climbing that activates the gluteal muscles. We mistreat our gluteal muscles with hours of compressive sitting and little in the way of full range hip movement. Many fitness clients and most physical therapy patients need some remedial gluteal training. Give these three drills a place in your triathalon training program.
Single Leg Bridges
Lay supine with the arms braced against the floor to stabilize the upper body. Bend the knees and place the feet flat on the ground. Lift the right leg up off the ground. Using the muscles in the back of the left leg, lift the hips up off the ground. Push up through the heel of the left foot and drive the left hip into full extension. Hold at the top for three seconds and then lower in a controlled manner. Perform ten repetitions on each leg. Common mistakes are allowing the pelvis to tilt and not fully extending the hip. Hamstring cramping is an indication that you are not using the glutes enough and need to focus on creating a better mind to butt connection.
The squat movement pattern is a skill that is easier to teach if you add some load. You can use either a dumbbell or a kettlebell for this exercise. It has been my experience that the exercise is easier to learn with a kettlebell. Hold a kettlebell by the horns, with the elbows down, and the kettlebell close to the chest. Keep the chest proud and pull the abdominal muscles tight. You may have to experiment with foot placement as everyone has different hips. The position you would place the feet if you were going to jump is a good starting point. Initiate the squat by pushing back the hips. Keep the torso tall and descend. Let your pelvis fall between the hips. The elbow should drop down between the knees. Nothing will inhibit your progress more than thinking about how you are moving during goblet squats. Keep your brain quiet and get in some repetitions. Effort has amazing capacity to improve motor control. Perform ten repetitions.
Mini Band Monster Walk
Your will need a mini resistance band–a nine inch loop of resistance band, (two dollars from performbetter.com). Most fitness clients will do well with a green or yellow mini band. Place the mini band loop around both legs just above the ankles. Assume an athletic stance with the feet straight ahead, knees bent, and hips flexed. The band should be held taught throughout the exercise. Imagine your feet are standing on railroad tracks. Walk forward for ten steps on each side, keeping the feet over the railroad tracks. Walk backward for five repetitions on each leg. Try to keep the hips and shoulders level throughout the exercise.
Once you have mastered all three exercises, build your gluteal and hamstring performance by traveling through the program for two or three trips.
- single leg bridges R and L x 10
- goblet squats x 10
- mini band monster walk x 10 each leg
View video of the exercises here: https://youtu.be/QeteeLPF4AU
Kat Wood, DPT, ATC
Triathlon Success: Core Connection
In the fitness world core stability training has gained a solid foothold and more people are getting away from spinal damaging resisted twisting machines and the ever present sit up gizmo. Most people know how to perform a “plank” exercise and have added this drill to their fitness routines. Learning how to properly brace the core stabilizers and perform a sustained plank type isometric exercise will resolve back pain, improve the hip to shoulder girdle connection, and make you a better movement machine. The problem is most people never advance beyond the basic plank exercise. Triathletes need significant anti-rotation and anti-extension core strength and endurance. I have three drills that will help keep you strong and resilient in your quest to complete you first tri. Read the directions and give these activities a place in your fitness program.
Alternate Single Arm Planks
Position the body in a toes and elbows plank, but separate the legs so the feet are wider than the shoulders. Lift one arm up at a 45 degree angle in relation to your body and hold for five seconds. Lower the arm back down and try the other arm.
If you are unable to perform the alternate arm plank on the floor, regress the exercise by placing the hands on a bench in a push ups position. Lift one arm up at a 45 degree angle in relation to your body and hold for five seconds. Lower the arm back down and try the other arm. How many and much? Perform three to five repetitions on each arm. Work up to longer hold times instead of more repetitions. Five repetitions on each arm with a ten second hold is a good goal.
You need a cable machine or resistance tubing set at mid torso level. Position your body at a 90 degree angle in relation to the pull of the cable. Assume an athletic posture with the feet at least shoulder width apart and the spine neutral. Push the hips back a little and keep a slight bend in the ankles and knees. You should look like a tennis player preparing to return an opponent’s serve. Use a strong overlap grip on the handle and set the hands in the middle of the chest. Brace the midsection and hips and move the handle out in front of the body and then back to the chest. Select a resistance level that permits execution of all repetitions without losing the set up posture. If one side is more difficult, start the exercise on that side. Perform fifteen repetitions on each side.
Many of us have terrible respiratory patterns. We are unable to fully inhale and exhale when under any physical stress. The Pallof Press can be used to improve respiratory control. Use the same set up and press the cable out. Hold the cable with the arm fully extended while inhaling for four seconds and exhaling for six seconds. Bring the arms back in and then repeat. Perform four of five inhale / exhale respiration repetitions on each side.
View the video here: View Video
Michael S. O’Hara, PT, OCS, CSCS
Triathlon Success: Hip Flexor Function
Two of the most important muscles for efficient running and a pain free set of knees are not visible in the mirror. Most people have never heard the names of these muscles. Located deep inside the body, covered by innards and all too often, layers of mesenteric fat, these muscles labor unloved and forgotten. Triathletes interested in optimal performance and a body that remains injury free should give some attention to the iliacus and psoas muscles.
Five muscles flex the hip–bring your femur forward. Three of the hip flexors attach to the front of your pelvis and run down the front and sides of your thigh. They are the sartorius, tensor fascia latae, and the rectus femoris. Two of the muscles attach to your spine and posterior pelvis and travel across all of the lumbar vertebrae, the sacroiliac joint, and the front of the hip joint. They are the iliacus and psoas muscles. The sartorius, tensor fascia latae, and the rectus femoris can lift your femur to parallel, 90 degrees hip flexion, and no further. The iliacus and psoas are responsible for lifting the hip above parallel. Many people have very weak iliacus and psoas muscles and are unable to flex the hip above 90 degrees.
Multi Joint Control
“Hip flexor” is a very simplistic description of the function of the iliacus and psoas muscles. The iliacus and psoas flex the hip, but they also rotate the hip, stabilize the pelvic girdle / lumbar spine, decelerate hip extension and co-contract with a team of muscles to hold us upright. Properly functioning iliacus and psoas muscles keep the pelvis stable when you walk or run and this mitigates stress on the knees and lower back. When the iliacus and psoas muscles are weak, the pelvis tilts forward and backward. This rotates the femur in and out and twists the knee. Your knee joint likes to bend back and forth and dislikes any extra rotation. Extra knee rotation wears out the back of the kneecap (patella) and places stress on the supportive cartilage (medial and lateral meniscus) of the knee. A triathlete with a wobbly pelvis places significantly more stress on their lumbar spine.
Riding a bike shortens and neurologically anesthetizes the iliacus and psoas muscles. A tight psoas muscle compresses the lumbar vertebrae together and increases pressure in the lumbar discs. Athletes with “quad strains” often have pain in the sartorius and rectus femoris muscles that has been brought on by overuse of these muscle as they compensate for a weak iliacus and psoas muscles. Tight and inhibited iliacus and psoas muscles are responsible for the wobbly gait pattern you frequently see as the triathlete transitions from the bike to the run. Two drills that will improve the function of the iliacus and psoas muscles are listed below. Read the directions and watch the video.
Standing Hip Flexor Isometric
The Standing Hip Flexor Isometric drill functions as both an evaluation and a method of restoring iliacus and psoas function. If you struggle with this exercise, you need to spend some time and effort on improving the performance of your iliacus and psoas. Listed below is a description of the exercise and several activity regressions and progressions.
You need a box or exercise bench. The taller you are, the higher the bench. Six feet tall, try a bench that is 24 inches high. Five foot, four inches, try a twelve inch box. A mirror for visual feedback is helpful. Stand with the right foot on the bench and the left foot on the floor. Hold a pvc pipe, broomstick, or golf club overhead. Brace the abdominal muscles to keep a tall spinal position and tight lordosis (inward curve) in your lower back. Lift the right foot off the bench by pulling the thigh up with the muscles in front of the hip. Hold the foot off the bench in a solid and stable position for five seconds and then lower. Do not let the position of the spine change. Do not bend the left knee or tilt the pelvis. The only joint that moves is the right hip. Athletes should be able to lift and hold the right knee 30 degrees above waist level. Start with sets of three repetitions and alternate sides. As you get stronger, increase the duration that you hold the foot up to ten seconds. If one side is weaker than the other, perform more repetitions or an extra set on that side.
Bench Assisted Hip Flexor Stretch
This drill will improve hip extension range of motion and enhance mobility in all of the hip flexor muscles. Bicyclists often have very flexed lumbar spines and limited lumbar and/or hip extension. This mobility exercise is the antidote for the physical restrictions created by too much time in the saddle.
You will need an exercise bench or a padded chair that is 12 to 16 inches tall. Place a cushion or Airex pad directly in front of the bench. Set up with the left foot on the floor in front of the Airex pad and aligned with the left hip. Place the right knee on the Airex pad and the front of the right foot up on the bench. Stay tall through the spine and hold the position for twenty to thirty seconds. For many people this will be enough stretch. If you are able take the arms overhead. Work further into the movement by bending the front knee and moving forward. Repeat on the other side.
Video of these exercises can be found here: View Video
Michael S. O’Hara, PT, OCS, CSCS
Triathlon Success: Foot Fitness
Foot and ankle injuries are the number one problem in the sport of triathalon. The thousands of spins on the bike, impacts on the run, and kicks with the swim can take a toll. Some preventative training can help speed tissue recovery in your feet and safeguard the ankles.
The foot and ankle are made up of twenty-six bones that are controlled by an elaborate combination of intrinsic and extrinsic foot muscles. A web of fascia interconnected to the muscles creates a dynamic sling that gives our foot form and acts as a spring to propel the body through space. Our feet evolved to guide us over an ever-changing environment of varying surface with minimal support from footwear. Modern footwear, deconditioning, and prior injuries can all take a toll on the functional mobility and strength of the foot and ankle. Preventative exercise activities can go a long way to prevent painful injuries in the lower leg and foot. Watch the video and give these activities a try.
You can perform this exercise throughout the day and it will help keep your feet healthy and strong. Point the foot (plantarflex the ankle) and flex all of the toes. Draw the foot up (dorsiflex the ankle) and keep the toes flexed. Extend the toes while keeping the foot pulled upward. Point the foot downward while keeping the toes extended. Keep the foot pointed and flex the toes. Move through this exercise in a steady and deliberate fashion. Take time to feel the muscles activate and stretch in the foot and lower leg. Repeat the “foot wave” for five to ten repetitions.
Short Foot Drill
The muscles on the bottom of the foot are called the foot intrinsics. The foot intrinsics function in a manner similar to the core muscles of the torso. Their job is to brace the foot so it can transfer forces through a stabilized series of boney arches. Weak or slow to respond foot intrinsic muscles impede the foot’s capacity to decelerate forces. The short foot drill will improve foot intrinsic muscle performance.
To perform the short foot drill on the right foot, place the right foot flat on the ground and place the left foot back. Bend the right knee about 20 degrees and lift the left heel off the ground so more weight is on your right foot. Lift and spread the toes of the right foot. Lower the toes back to the ground and grip the floor with the big toe. Contract the muscles on the bottom of the foot. You should feel a lifting of the foot arches. Tighten the muscles of the right leg from the calf to the hip and lift the pelvic floor. Hold this tension in the foot and leg for ten seconds and then release. Perform five repetitions.
Soft Tissue Mobilization
Treat the soft tissue structures of the ankle and foot with a consistent program of massage. Three or four times a week, take five minutes and perform some massage stick work to the muscles of the lower leg. Find a tennis ball and roll out the plantar aspect of the foot. Deep soft tissue work helps improve circulation, prevents aberrant scar tissue formation, and promotes tissue elasticity.
Age brings lower leg arthritic changes and circulatory deficiencies. These can create pooling of inflammatory byproducts in the feet and ankles created by a week of triathalon training activity. Cooling the feet and ankles in an ice bath can help break the chemical cycle of inflammation and enhance recovery. At the end of a training day, fill up a bucket with water and lots of ice. I like to get most of my lower leg under the water. Try fifteen to twenty minutes every other day.
Watch our Foot Fitness video for demonstration of these exercises: View Foot Fitness Video
Kat Wood, DPT, ATC
Triathlon Success: Movement Prep
Limited mobility is a fairly common finding among recreational runners, bikers, and swimmers. Very often, the deficits are worse on one side of the body. A movement asymmetry makes any triathlete more susceptible to injury. As a group, triathletes benefit greatly from the diligent application of a simple movement preparation program. Movement preparation drills help prevent and/or train away mobility impairments.
Movement Prep is Superior to Stretching
For athletes, movement preparation drills are more beneficial than static stretching. Movement prep improves postural reflexes, deceleration skills, standing balance, and coordination. Any extra mobility you achieve with training must be controlled by your neuromuscular system during varying level of fatigue. Movement prep develops all aspects of athleticism. The two exercises I recommend for endurance athletes are the moving posterior lunge and the world’s greatest stretch.
Moving Posterior Lunge
Most runners and bikers have tight hip flexors, weak lateral gluteals, and limited lumbar extension range of motion. This exercise will improve all of these areas.
Stand tall and step backward with your right leg. Try to get the right knee close to the ground, stay balanced, and keep the torso tall. At the same time, bring your arms overhead. Push up with the left leg, lower the arms, and return to standing. Repeat with the left leg and move down the track with alternating posterior lunges. Perform ten repetitions on each leg. Perform five times on each side. Common mistakes are allowing the torso to tip forward and caving inward of the front knee.
World’s Greatest Stretch
Running, biking, and swimming are primarily single plane motions. Runners do little in the way of rotational motion and often have restricted thoracic spines. The world’s greatest stretch opens up the thoracic spine and will reveal any limitation in movement capacity between the right and left legs.
You need about ten yards of open space. Stand tall and step forward with the left leg. Place the hands down on the ground and attempt to lower the pelvis to the ground. Pause, support the torso with the right hand, and turn toward the left leg. Reach the left hand to the sky and pause in full rotation. Return the left hand to the ground outside the left knee and gently attempt to straighten the left knee and then pause. Bring the right leg up and return to standing. Repeat the drill with the right leg stepping forward. Perform five times on each side. Many mistakes are made with this drill. Please persevere as it is worthy of your efforts.
View the video here: Movement Prep Video
Michael S. O’Hara, PT, OCS, CSCS
Triathlon Success: Myofascial Management
Triathlon training is a vigorous and demanding athletic endeavor. The successful triathlete is often the one with the fewest injuries and the best recovery capacity. Soft tissue mobilization with a roller helps decrease pain, improve mobility, and will speed up recovery between bouts of exercise. Few of us can afford or dedicate the time to a daily massage. The roller is the best do-it-yourself method of enhancing myofascial recovery. Triathletes should begin every training session with five to ten minutes of roller work.
In the book, Anatomy Trains, Thomas Myers describes the interconnected webs of fascia and muscles that move our joints and hold us upright. The human body is not just isolated muscles, but rather a series of interconnected lines of muscles and fascia that are reliant on one another to produce efficient movement. The mechanical stress created by a roller keeps the tissue lines sliding and gliding across one another. It removes neural and mechanical inhibitors of movement and makes exercise easier.
More varieties of rollers have come on the market and whenever we are faced with a lot of choices, it becomes more difficult to make a decision. In this short presentation, I have some suggestions on the proper roller for the job.
Rollers are available in three foot and one foot lengths. I find the longer versions easier to use. Bigger and taller athletes generally do not do well with a short roller.
The best roller for you will depend on your tissue tolerance or how sensitive you are to the compressive forces of the roller. If you are new to foam rolling, a low density white foam roller is softer and will create less discomfort. As you develop better tolerance to rolling, you can progress to a firmer black foam roll. It has been my experience that the white rolls break down faster than the firmer black versions, so be prepared to replace a white roll fairly often.
Hollow, pipe style rollers are newer to the market and I have had good results with two products. The Grid Trigger Point roller is a cushioned hollow pipe with a grid pattern across the surface of the roller. Many smaller clients and patients report they like the short version of the Grid roller. Another hollow pipe version is the Rumble Roller. This product has a series of projections that extend from the roller surface. Self-soft tissue mobilization with a Rumble Roller is more uncomfortable than any other roller I have used. It is a more aggressive treatment, but I have found it works well for individuals with thicker and denser muscles.
So how often should you, a triathlete, use a roller? I like to stay active, pain free, and maintain my posture, so I use a roller every day. Physical therapy patients with painful myofascial restrictions may need to foam roll two or three times a day. Including five to ten minutes of foam rolling prior to a training session is the preventative medicine that will keep you on the road and out of the doctor’s office. Watch the video that accompanies this article and get going on a roller.
View video here: Roller Video
Michael S. O’Hara, PT, OCS, CSCS
Very Short Term Running Preparation
I was recently asked by a fitness client to post exercise recommendations that would prepare her for outdoor distance running. This person was two weeks away from being out on the road, running two or three miles a day. She is middle aged, has a prior history of lower back pain, and her goal was to lose fifteen pounds and “tone up”. Given such short notice, these are my recommendations.
Perform soft tissue work on a daily basis. Foam roll the legs and use a lacrosse ball on the plantar fascia. The vast majority of overuse injuries in runners happen in the lower legs and feet. Attempt to unwind the myofascial distress created by 600-700 foot impacts a mile.
Improve your reciprocal hip pattern–one hip goes back and the other goes forward. Most general fitness clients have glaring deficits on one side. Perform some split squats, posterior lunges, step ups, and or walking lunges. If you struggle with these activities, I would reconsider running as a fitness activity.
Wake up your gluteals. Every day, perform fifty or sixty bridges, hip lifts, or leg curls. You need super gluteal strength / endurance to run distances and avoid lower extremity injury. If your butt gets sore from fifty bridges, you need to do them more often.
Running is a skill and most recreational runners need some practice. Running hills will improve gait mechanics, enhance hip extension, and decrease deceleration forces. Find a fifty-yard hill. Run up the hill and walk back down. Perform five hill runs.
You are always better to run too little than to run too much. Start with very short runs– no more than half a mile. Increase your total weekly mileage by no more than five percent a week.
You can’t do this in two weeks, but this is my big recommendation to all future runners. Lose the extra weight before running. As a method of fat loss, distance running has a poor track record. It tends to elevate the hormones that make you hungry, and physiological adaptation to distance running happens fairly quickly. Extra adipose makes you far more likely to develop a running related injury. I know the guys and gals you see running miles and miles every day are lean. Please remember that lean runners are successful with running because they possess the optimal body mass to run long distances. They did not start heavy and become lean. Put a fifteen pound weight vest on that guy or gal and everything will change. Their gait will lose efficiency and become less graceful. The extra fifteen pounds of load creates the biomechanical overload that makes them much more likely to suffer an injury.
My final recommendation is that you not become disappointed if you develop pain. A runnersworld.com poll conducted in 2009 revealed that 66% of respondents reported a running related injury that year. The statistics indicate that one third of the participants at you local 10k fun run will require medical attention for a running related injury over the next year. Have the good sense to stop when the pain begins.
Michael S. O’Hara, PT, OCS, CSCS
Are You Ready?
Spring At The Physical Therapy Clinic
The weather is warming up and soon we will leave the heated, insulated, safety of our home gyms and fitness centers. The spring migration back to tennis, soccer, pickleball, golf, fitness running, ultimate Frisbee, and stadium steps will begin. My physical therapy question is– Are you ready for these new challenges? Has your fitness program prepared you to withstand the rigors of these spring endeavors? This checklist should help you answer the question.
Have you been performing most of your fitness activities in standing?
Nearly every sport and most household chores are performed in a standing position. During most of my visits to commercial gyms, the majority of the activity I witness is in the supine, seated, or heavily supported positions. If your goal is to move better and remain free of injury, then 90% of your exercise should be performed in standing.
Do you practice moving in all directions?
Nearly every sport involves moving side to side, forward-backward, and in a rotational pattern. Basketball, soccer, golf, and tennis all require you to accelerate and decelerate movement in all directions. Most gym activities are predominantly sagittal plane– forward and backward. You ride on the elliptical, spin the bike, and run on the treadmill for months, and your spring visit to the tennis court results in a twisted ankle because you are unfamiliar with side to side movement patterns.
Have you been working on better balance?
Balance is a skill that tends to deteriorate with age, injury, and a sedentary lifestyle. Many commercial exercise machines take all balance demands away. The elliptical, spin bike, recumbent bike, rower… all are heavily supported. Proficiency with single leg stance balance prevents injuries and improves performance. The older and more deconditioned you have become, the more your fitness program should include single leg stance balance training.
Do you perform any explosive exercises?
We get slower before we get weaker, and life is an up-tempo game. We need to perform exercise that enhances quickness and improves control of deceleration forces. What you do in the gym is reflected in how well you can move during activities of daily living. If you continually exercise at slow tempos, you will get better at moving slowly. If you train explosively, you get better at moving at faster speeds. The capacity to decelerate a fall requires fast reactions. Gracefully traveling up the stairs and getting out of the car are only improved with exercise that enhances power production and speed of movement.
Michael S. O’Hara, PT, OCS, CSCS
Advice From The Experts At Fenton Fitness
Tara Parker-Pope wrote a great article in the October 17, 2016 edition of The New York Times entitled “The 8 Health Habits Experts Say You Need in Your 20s.” While I agree with some of these recommendations, we at Fenton Fitness and Fenton Physical Therapy have some suggestions of our own.
#10–Establish A Veggie And Protein Habit
One of the biggest deficits I see in many food logs is the lack of protein consumed. We have been conditioned to snack on high carb/highly processed food, so eating more protein can be a difficult shift. When I do see protein, it’s in the higher fat varieties of sausage, bacon, burgers, etc. It would benefit younger individuals to start adding healthy doses of protein to their diets as soon as they are responsible for their own food preparation. Shoot to have some form of lean protein as the base of your meal along with a couple of servings of vegetables. Once you have that base (taking up ½ to ⅔ of your plate), then you can add in whole grains, starchy carbs, fruits, dairy, healthy fats, etc. Protein increases your metabolic rate more than any other nutrient, aids in recovery, helps build and maintain muscle mass, and much more. We recommend 25-35% of total calories to come from protein, or 0.8-1gram/pound of body weight. Most individuals should shoot for 4-8 servings of vegetables per day as well.
-Jeff Tirrell, CSCS, Pn1
To read the article, click on the link below: